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Keywords:

  • advocacy;
  • African and Caribbean;
  • black and minority ethnic;
  • empowerment;
  • mental health

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Background  Advocacy has a critical role to play in addressing concerns about access to appropriate mental health care and treatment for African and Caribbean men.

Aim  To investigate good practice principles and organizational models for mental health advocacy provision for African and Caribbean men.

Study design  The study consisted of: (i) A systematic literature review. Bibliographic and internet searching was undertaken from 1994 to 2006. The inclusion criteria related to mental health, advocacy provision for African and Caribbean men. (ii) Four focus groups with African and Caribbean men to explore needs for and experiences of mental health advocacy. (iii) An investigation into current advocacy provision through a survey of advocacy provision in England, Wales and Northern Ireland. (iv) Twenty-two qualitative stakeholder interviews to investigate the operation of mental health advocacy for this client group. The study was undertaken in partnership with two service user-led organizations and an African Caribbean mental health service.

Results  Primary research in this area is scant. Mainstream mental health advocacy services are often poor at providing appropriate services. Services developed by the Black Community and voluntary sector are grounded in different conceptualizations of advocacy and sharper understanding of the needs of African and Caribbean men. The lack of sustainable funding for these organizations is a major barrier to the development of high-quality advocacy for this group, reflecting a lack of understanding about their distinctive role.

Conclusions  The commissioning and provision of mental health advocacy needs to recognize the distinct experiences of African and Caribbean men and develop capacity in the range of organizations to ensure equitable access.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Advocacy is typically defined in terms of giving disadvantaged groups a voice and is rooted in an understanding of unequal relationships between providers services and service users. It is concerned with seeing the world from the service user’s perspective.1 For the past twenty years, attention has been drawn to the disproportionately negative experiences of African and Caribbean men within mental health services.2 Mental health advocacy thus has a potentially powerful role to play in securing the most appropriate care and treatment for African and Caribbean men. This paper reports the findings of a systematic review and additional primary research to investigate the organizational models and principles that support good practice in advocacy for African and African Caribbean men using mental health services.

Background

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Concerns about the anomalous treatment of African and Caribbean men within mental health services are well established; they are more likely to be detained under the Mental Health Act, experience more adverse pathways into care and are less likely to access primary care and psychological therapies.3–7 The potential of advocacy to address these issues has been identified and recommended by other research8 and national policy.9 The Mental Health Act 200710 introduced a statutory duty in relation to independent mental health advocacy (IMHA) in England and Wales, with PCTs becoming responsible for commissioning IMHA services from April 2009. Subsequent guidance has made it clear that considerations of diversity are critical to the provision of effective high-quality IMHA services.11,12

As there has been little research into advocacy in general and in provision for black and minority ethnic (BME) communities in particular, the Social Care Institute for Excellence (SCIE) commissioned us to undertake this study.13 A previous study involving systematically mapping mental health advocacy provision for local African, Caribbean and South Asian Communities in Yorkshire and Trent identified little specific provision.14 This study reported that needs were not being met by mainstream advocacy organizations but were being addressed to some extent by community organizations. The authors concluded that the conceptualization of advocacy, with its emphasis on individuality, is problematic for these communities. However, standards and guidelines15 for the provision of mental health advocacy have been produced and these include responding to diverse needs, although the extent to which this has been implemented has not been evaluated.

Aim

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

The overall study aim was to identify the evidence for different organizational forms and good practice principles for the provision of mental health advocacy with African and Caribbean men in England, Wales and Northern Ireland.

The specific objectives were to:

  • 1
     Identify current organizational arrangements and delivery of mental health advocacy for African and Caribbean men.
  • 2
     Explore meanings of advocacy, access to and experience of mental health advocacy, the principles and characteristics that need to underpin the delivery of mental health advocacy to African and Caribbean men and preferences for how mental health advocacy services should be organized from the perspective of African and Caribbean men and advocacy providers.
  • 3
     To investigate characteristics of high-quality effective services; organizational arrangements and factors that have facilitated or hindered the development of appropriate advocacy.

Methodology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

The method involved four elements: a systematic literature review, focus groups, a national survey of advocacy practice and qualitative interviews. The literature review, national survey and focus groups were undertaken concurrently with the emergent findings used iteratively to inform the final phase of stakeholder interviews. The study involved service users16 through partnership with three voluntary sector organizations that have well-developed expertise in this area: African and Caribbean Mental Health Service, Manchester; Equalities, the National Council for Disabled People and their Carers from BME Communities and Lancashire Advocacy. We refer to these organizations as partner organizations in this paper.

Systematic review

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

The steps undertaken for the systematic review are illustrated in Fig. 1.

image

Figure 1.  Overview of the systematic review method.

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An inclusive search strategy was adopted and the review included all descriptive, evaluative or empirical material reporting the provision of, need for, or experience of advocacy services for African and Caribbean men. Evidence was limited to literature published in English from 1994, when the NHS Executive instructed all service providers to collect data on service user’s ethnic origins to July 2006. The sources are summarized in Table 1. Secondary references and citation searches were undertaken for previous reviews and all included papers, and personal communication with advocacy services and experts in the field was also undertaken.

Table 1. Details of sources searched
SourcesDetails
Bibliographic databasesThe Campbell Collaboration Library, MEDLINE, EMBASE, CINAHL, AMED, ISI Science Citation Index, PsychInfo, IBSS, Social Care Online, NHS National Research Register, ReFeR, ZETOC, HMIC, CSA Sociological Abstracts, Index to Theses, COPAC, Social Work Abstracts, Social Science Abstracts, Social Policy and Practice and SCOPUS
Web-based sourcesGeneral and mental health sources e.g. MIND Client group and advocacy specific websites e.g. Action for Advocacy Generic internet gateways: e.g. Google Web-sites of regulatory and statutory organizations, e.g. Department of Health
Hand-searching of non-indexed journalsDiverse Minds, Planet Advocacy

The full list of sources searched is provided in the research report available at http://www.scie.org.uk/publications/knowledgereviews/kr15.asp.

The inclusion criteria were as follows:

  • 1
    Client group: Black Caribbean, Black African, African Caribbean, mixed African/White, mixed Caribbean/White, Black British;
  • 2
    Definition of mental health: general descriptions, e.g. mental illness; specific diagnoses, e.g. schizophrenia, depression; dual diagnoses including learning disabilities and substance misuse with mental illness;
  • 3
    Advocacy provision: within primary care, voluntary sector, mental health services, forensic and secure services and the criminal justice system.

Two reviewers independently screened and filtered a total of 4854 references. Papers were classified according to type (research, evaluation, information, service description, practice standards/guidelines) Two reviewers independently extracted data relating to the client group, intervention details, context of service provision, outcomes and factors influencing implementation. The quality of the evaluation studies was evaluated using the TAPUPAS standards described by Pawson et al17 and evaluated by Long et al18, and the AGREE criteria19 were used to appraise the standards and guidelines for advocacy provision.

A conceptual framework was developed from the work of Rai-Atkins14 and Carlisle,20 bringing together two dimensions of advocacy: independence–interdependence and empowerment and protection/prevention, as illustrated by Fig. 2. This conceptual framework was used for analysis of the service descriptions.

image

Figure 2.  Conceptual framework for analysis of advocacy service descriptions (adapted from Carlisle, 200020).

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Primary research

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Focus groups

Four focus groups were undertaken between April and August 2006 with 25 (8, 7, 7 and 4 participants, respectively) African, African Caribbean and dual heritage mental health service users, ranging in age from early 20s to mid-40s in four urban locations. Demographic information and information about mental health service use by African and Caribbean men from the Mental Health Minimum Dataset was used to identify areas with high numbers of African Caribbean men as potential sites for the focus groups. Different methods for recruiting participants were tried and the most successful method proved to be via voluntary and community organizations, who invited known service users to participate. The topic guide covered the following:

  • 1
     understandings of the term mental health advocacy;
  • 2
     access to and experiences of advocacy;
  • 3
     good practice principles and service design characteristics that African and Caribbean men view as critical in the delivery of specialist mental health advocacy;
  • 4
     preferences for how mental health advocacy services should be organized to meet the diverse needs of African and Caribbean men.

National survey

Through internet searching and from the databases of the partner organizations, 669 potential advocacy providers were identified in England, Wales and Northern Ireland. After duplicates were removed, criteria were applied to finalize inclusion on the database. The inclusion criteria were provision of mental health advocacy services for adults that either targeted African and/or African and Caribbean men, BME communities or provided a service for the whole population in a locality. Umbrella organizations that did not provide a direct service but provided training or coordination were excluded. This left 391 organizations, which were classified and a typology of the different organizational arrangements developed. The organizations fell into three broad categories, namely African and/or African and Caribbean–focused organizations (n = 87); BME Community–focused organizations (n = 31); and advocacy organizations (n = 273). A survey questionnaire was developed to collect information on:

  • 1
     the principles and aims of the service;
  • 2
     types of provision and main services provided;
  • 3
     needs of African and Caribbean men in relation to mental health advocacy;
  • 4
     views on provision of mental health advocacy to this client group, including good practice principles and service design characteristics to underpin effective delivery;
  • 5
     facilitators and barriers to effective service provision.

Data collection proceeded via two stages:

  • Stage one – the survey questionnaire was sent via e-mail or post to the 391 organizations in database. The response rate providing information about provision was low (8.1%), although it was not possible to locate 6% of the sample. Feedback from potential respondents indicated a combination of time pressures, changes to organizations and the length of the survey questionnaire as potential barriers to completion.

  • Stage two – telephone contact to recruit non-responders to the mailed survey to improve the response rate, followed by telephone interviews with managers using the survey questionnaire to undertake the interviews. In order to ensure that the different organizational arrangements for provision of mental health advocacy to this client group were sampled, the typology developed from mapping the organizations on the database was used to purposively guide further recruitment. In total, data on 52 organizations (i.e. 12% of the total sample) were collected, as detailed in Table 2. The major gap in the sample is for service user groups providing mental health advocacy through peer support, although these constituted only 3.1% of the total sample).

Table 2. Sample in the practice survey
Organizational typeNo of respondents (%)
  1. BME, black and minority ethnic.

African and Caribbean (AC)-focused
 AC mental health advocacy3 (6)
 AC mental health service5 (9.5)
 AC service user group0 (0)
 AC community organization7 (13.5)
  Total15 (29)
BME-focused
 BME mental health advocacy4 (7.5)
 BME mental health organization7 (13.5)
 BME service user group0 (0)
 BME community organization3 (6)
  Total14 (27)
Advocacy-focused
 Generic advocacy7 (13.5)
 MH advocacy15 (28.5)
 MH user group1 (2)
  Total23 (44)
  Grand Total52 (100)

Stakeholder interviews

A more detailed examination of the provision of mental health advocacy for this client group was undertaken through stakeholder interviews (22 people in total including seven service users, six commissioners, four mental health service providers in three different locations from the focus groups. Demographic information and information about mental health service use by African and Caribbean men from the Mental Health Minimum Dataset was used to identify the locations and ensure a geographical spread for data collection. Five people with a national reputation and expertise in the field were identified through author tracing and recommendation from advocacy services and also interviewed. The topic guide for the interviews covered the principles and characteristics that need to underpin the delivery of mental health advocacy to African and Caribbean men as well as experience of facilitators and barriers to delivery.

Analysis and synthesis

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

The qualitative interviews, focus groups and survey data were analysed using systematic thematic analysis. The analysis adhered to published criteria for qualitative research.21 The conceptual framework for analysing the material reflected the research objectives, and the key headings were as follows:

  • 1
     Needs of African and Caribbean men relevant to advocacy;
  • 2
     Outcomes from advocacy;
  • 3
     Experience of advocacy;
  • 4
     Characteristics of advocacy services;
  • 5
     Good practice principles for advocacy with this client group;
  • 6
     Service design characteristics;
  • 7
     Organizational barriers and facilitators for the development of appropriate advocacy for African and Caribbean men.

The findings from the literature review and the primary data sources were combined to provide a description of current models of mental health advocacy provision for African and Caribbean men. The evidence from the different data sources was then compared to evaluate the strength of evidence for different ways of organizing advocacy, and statements relating to elements of good practice were extracted and synthesized.

Limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

The major limitation of the literature review is the lack of evidence relating to the review question, in particular the absence of evaluative studies in this area and studies that have focused on advocacy for African and Caribbean men. The limited response rate to the national survey is also a significant limitation, although efforts were made to increase this and ensure that the different types of organizational arrangements were reflected in the final sample. Further, as equalities monitoring was not universal and the systematic evaluation of outcomes seriously lacking, the conclusions from this study are tentative indicating a need for further research.

Ethical approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Ethical approval was secured from COREC through Hertfordshire 1 Research Ethics Committee and the Faculty of Health’s Ethics Committee at the University. The study was also approved by the relevant Local Research Ethics Committees where the qualitative interviews took place.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Literature review

A total of 148 papers were identified that met the inclusion criteria: 51 primary (i.e. directly relevant) and 97 secondary (i.e. indirectly relevant to the client group or mental health advocacy). An overview of the papers meeting the inclusion criteria is provided in Table 3. Of the 51 papers that were directly relevant, only 10 papers were identified referring to 9 evaluative studies, with the remaining largely being unpublished service descriptions (n = 36: 32 in England; three in Wales and one in Northern Ireland). Of the 97 secondary papers, 11 included standards or guidelines relevant to mental health advocacy and 12 papers identified factors relevant to the implementation of mental health advocacy with the remainder largely relating to the needs of African and African Caribbean men relevant to advocacy (n = 38) or calling for action to be taken (n = 30). In particular, these papers highlighted the negative relationship between mental health services and African and Caribbean men and the need for action, including advocacy to address this negative dynamic.

Table 3. Papers meeting criteria for inclusion
Type of evidenceClassificationNumber
PolicyPrimary0
Secondary12
Standards or good practice guidelinesPrimary3 also included in systematic inquiry
Secondary11
Training course descriptionsPrimary0
Secondary3
Service or project descriptionsPrimary36: 4 papers refer to 2 projects and 1 paper refers to over 20 projects, although not entirely clear how many provide advocacy
Secondary2
Systematic inquiryPrimary10 referring to 9 studies
Secondary38, the majority focused on needs or epidemiological differences
Conference proceedingsPrimary0
Secondary1, collection of papers
Commentary including service user and practitioner commentaryPrimary4 predominantly referring to the studies above.
Secondary30 highlighting findings from key reports and/or calling for action to be taken. Includes a small number of theoretical papers

Table 4 provides a summary of the nine evaluative studies. These studies either considered advocacy as part of broader mental health service provision for African and Caribbean communities or considered advocacy provision for African and Caribbean men as part of a study of mental health advocacy for a wider population.

Table 4. Overview of evaluative studies
Study detailsFocusType of study
Advocacy focusPopulation focusContext
  1. BME, black and minority ethnic.

Relevance to study group
 Chouhan, K. & McAttram, M.24Mental health advocacy as part of broader mental health service provisionAfrican and Caribbean communitiesBME and BCVS providing mental health servicesDescriptive survey of service providers and funders
 Christie, Y., Hill, N.25Mental health advocacy as part of broader mental health service provisionBlack and minority ethnic communities with specific focus on African and Caribbean communitiesBME mental health services in England and WalesDescriptive survey
 Watters, C.26Mental health advocacy as part of broader mental health service provisionBlack and minority ethnic communities with specific focus on African and Caribbean communitiesAfrican and Caribbean mental health service for people with serious mental illness living in an inner city areaDescriptive
Relevance to advocacy provision
 MIND32Mental health advocacyGeneral with specific reference to African Caribbean communitiesCommunityDescriptive survey
 Foley, R. & Platzer, H23 Also Foley, R. & Platzer, H.36Mental health advocacyGeneral with reference to BME communitiesMental health advocacy providers across LondonDescriptive survey using mixed methods
 Rai-Atkins, A. & Jama, A.A., Wright, N., et al.14Mental health advocacyBlack and minority ethnic communities30 mental health advocacy providers, both mainstream and BMEDescriptive survey and multiple case study
 McKeown, M., Bingley, W. & Denoual. I37Mental health advocacyGeneral with specific reference to African Caribbean communitiesMental health advocacy providers (mainstream and BME) in a medium secure and high-dependency unitsProcess evaluation
 Coleman, C., & Dunmur, J.38Mental health advocacyGeneral with reference to BME communitiesMental health advocacy providers (mainstream and BME) in SheffieldDescriptive survey
 Barnes, D. & Tate A.22Independent mental health advocacyGeneral with reference to BME communitiesMainstream mental health advocacy provider in a special hospitalProcess and impact evaluation

The studies were largely descriptive using survey methods to capture relevant perspectives, with only one study by Barnes et al.22 evaluating the impact of advocacy for people in secure services, including African and Caribbean men. The most relevant study was a mapping exercise of mental health advocacy for BME communities in Yorkshire and Trent undertaken by Rai-Atkins et al. (2002),14 although the results were not specfically disaggregated for different BME communities. The authors found that the mental health advocate role was less developed for minority groups, reflecting a lack of resources for BME advocacy, an imbalance of power and a lack of understanding amongst mainstream mental health advocacy services of cultural issues. This, and another mapping exercise across Greater London,23 identified a mismatch between the provision of mental health advocacy and needs at a local level resulting in gaps in provision for minority groups or those with specialist needs. The three papers that described advocacy as an integral element of African and Caribbean mental health services (Chouhan and MacAttram,24 Christie and Hill25 and Watters26) identified grass-roots credentials and skill as essential in engaging with African and Caribbean communities. This was supported by a case study undertaken by Platzer and Foley,23 who found that although only a minority of staff in one ACMHS were employed as advocates (17%), in reality nearly two-thirds of the time spent with clients was spent on advocacy (65%). The location of the advocacy service emerged as critical not only in terms of identity but also in terms of the nature of the advocacy.

Table 5 summarizes the results of mapping the service descriptions against the conceptual framework. Nearly all the service descriptions from advocacy-focused organizations described providing a professional model of advocacy, involving advocating on behalf of an individual. This type of advocacy was also described by the BME- and African and Caribbean–focused organizations but reference to community or collective advocacy was more frequently mentioned. This type of advocacy involves mental health as a collective or community concern27 and representing their member’s views in order to enhance their status.

Table 5. Analysis of advocacy service descriptions (N = 34 services)
Type of advocacy provision describedOrganizational type
Advocacy-focused (generic and mental health, n = 17)BME-focused (n = 8)African Caribbean–focused (n = 9)
  1. BME, black and minority ethnic.

Peer and/or self-advocacy52.3% (9)25% (2)11.1% (1)
Collective or community advocacy17.6% (3)50% (4)66.6% (6)
Professional advocacy94.1% (16)50% (4)55.5% (5)

There was agreement across the different sources of literature in relation to the cultural sensitivity of services and the importance of services being underpinned by a clear set of principles and standards to provide a framework for a basic standard of competence, including identity, faith, racism, gender and spirituality.14 A consistent theme both in the studies and service descriptions from BME advocacy and mental health services was the importance of shared African and Caribbean identity, including language, an appreciation of roots and black history, understanding the importance of religious and spiritual beliefs, the family as a foundation for the individual and recognizing the psycho-social basis for mental distress including the impact of racism.25,26

Focus groups

Although all the African and Caribbean men recruited to the focus groups had experience of using mental health services only a small number appeared to have experience of formal advocacy. The conceptualization and view of advocacy emerged as a factor influencing this. The term ‘advocacy’ did not necessarily have immediate meaning for participants and was sometimes interpreted as being part of statutory service provision, having strong legal connotations or described as befriending, particularly if provided by a BCVS organization.

Advocacy is a frightening word – don’t understand it. … Should be another word … It could be “Sparring-P”– a friend who would defend you, would be there for you. You know how strong the person is and they fight for you – you get the person to stand up for you.

[Service user]

Regardless of whether focus group participants had experience of advocacy, there was a broad consensus about the pressing need for appropriate advocacy, often framed in terms of addressing negative or coercive aspects of mental health services, particularly overmedication. Many focus group participants expressed well-developed ideas about self-advocacy, linked to their cultural identity and self-reliance and the need ‘to stand on your own two feet’.

The accessibility of advocacy provision was highlighted by the participants in terms of setting and the timeliness of access, stressing the need for advocacy to be available at key decision points, particularly during and after hospitalization, at or around the time of discussions about medication and other aspects of care planning. The quality of the relationship between the advocate and client was emphasized as central to effective mental health advocacy. This went beyond the need for an effective professional relationship to the need for human connection between the partners in the advocacy relationship and articulated as a desire for advocates who share cultural identity, language and a shared knowledge of forms of religion and spirituality, language (particularly patois) and local community: an advocate ‘like me’. This was related to the establishment of trust and respect reflecting mistrust in mainstream provision.

I think it is very important …. to go to a place where there are like minded people of the same colour going through similar problems as yourself and you don’t feel alone and you feel like you can communicate to certain people with regards to certain things which maybe very personal to you at that time.

[Service user]

Some focus group participants also thought it was important that advocates shared an experience of mental health problems. The approach of the advocate in terms of taking a holistic approach to mental health issues and helping the whole family, not just an individual, was also highlighted. As one participant commented ‘(if advocacy was to be perceived as useful) it needs to be an intervention right from the word go where members of their family could be educated and respond to our needs.’ This contrasts with the mainstream tradition of advocacy, which is provided on a one to one basis.

National survey

The development of the database for the national survey enabled a typology of different organizational models for the provision of mental health advocacy for this client group, as illustrated by Table 2. Organizational models broadly fell into three different types: African and/or African Caribbean–focused, BME-focused and advocacy-focused organizations, either generic of mental health specific and further detail on these different organizational models, including functions, staffing and advocacy provision, is provided in Table 6. Different types of advocacy services could be co-located, for example an African and Caribbean advocacy service located in community centre together with a generic mental health advocacy service. The majority of the organizations identified were in England. One BME mental health organization providing advocacy was identified in Wales and none in Northern Ireland, although mainstream mental health advocacy was provided in both areas.

Table 6. Description of types of organizational arrangements
Type of organizationOrganizationFunctionsStaffingAdvocacy provision
  1. BME, black and minority ethnic.

African and/or African Caribbean–focused
 African Community GroupsOften constituted around single national or ethnic groupLargely concerned with support for immigrants- information, advice giving (Bi-lingual), help in navigating bureaucracies, general support, and signposting to other services. Anyone with mental health difficulties is dealt with in this way, with little direct support for mental health, but do not rule this out.Small numbers of paid staff (2 or less) often staffed by volunteers.Mission is not necessarily articulated as advocacy, but work does have recognizable advocacy strands and often involves accompanying people to GP appointments and, if necessary, supporting people to get their point of view across.
 African and Caribbean Community welfare and social groupsMembership organizationsRaise funds for local charities, organize social and cultural events in community. Mutual support and solidarity networks, including supporting people with mental health issues, but is not the main focus. Systems of home-visiting, organized by regular volunteers, or more simply in terms of members looking out for each other. Some of these groups have premises others do not. Might offer health seminars and provision of health and welfare advice, and issues relating to African Caribbean people. Some members have background in health services and are well placed to offer advice. Some members are in families who have a relative with mental illness.Very much a voluntary enterprise little evidence of paid staff.Providing information and signposting to services.
 African and Caribbean Mental Health AdvocacyStand alone or more usually organized within a larger umbrella organization, offering alternative care services. Rarely may be part of a generic mental advocacy service.Culturally sensitive service, formal, professional model of advocacy. Sometimes targets broad health issues, sometimes focused explicitly on mental health.Those organizations that are just constituted for advocacy for African and Caribbean community tend to be small, employing 1–3 advocates, often part-time.Culturally sensitive advocacy
 African and Caribbean Mental health servicesCulturally sensitive services as an alternative to parts of the mainstream NHS. Often run in parallel or adjunct with cross referrals. Often based on social model of care rather than medical model.Alternative culturally sensitive services. Provide a range of direct services, including housing, group work and counselling. Often provide advocacy as an integral function.Some of these organizations are quite large, with one employing 32 staff in total across a range of organizations. One was small enough to employ just 4 staff.Can refer to support rather than advocacy, though some of the bigger services have specific advocacy services. All staff engaged in advocacy as part of their role.
BME organizations
 Multi-cultural groupsSimilar to African and African and Caribbean social and welfare groups.A range of social and welfare activities.Largely supported by volunteers, one had 2 staff.Similar to African and African and Caribbean social and welfare groups.
 African and African Caribbean and/or BME umbrella organizationsHost a number of different groups or services. May be a central coordinating group supporting other organizations.Capacity building and/or coordinating function. May also represent other groups.Vary in size- one large grouping was found, employing 68 staff across all organizations.May include support for fledgling advocacy groups but does not involve direct provision of advocacy.
 BME advocacy organizations Providing culturally sensitive advocacy for a range of BME groups. Sometimes these groups have other roles, sometimes staffed separately, for example carer support, befriending, or user development workers.Typically employ 3–4 staff.Culturally sensitive advocacy.
 BME mental health servicesMaybe established within the NHS or social services or independent.Alternative services or culturally sensitive services. Some provide direct services; others exist to work alongside established case-workers to improve the cultural sensitivity of their work.Staffing levels range from 2 to 6, typically with no more than one individual focused on African and Caribbean clients.Culturally sensitive advocacy.
Advocacy
 Generic advocacy servicesProviding advocacy across a range of client groups including mental health.Tends to be independent professional advocacy. Also citizen advocacy for people with learning difficulties. Collective and peer advocacy also provided but much less frequently than individual casework.VaryMay have developed to ensure cultural sensitivity but rare and the extent of this will reflect the local demography and existence of other advocacy providers.
 Generic mental health advocacy services As above, largely on a model of formal, independent, professional advocacy organized around individual casework. Often low numbers of BME service users unless specific initiatives have been developed to proactively engage. As above

The African and Caribbean– and BME-focused organizations providing mental health services, without exception, described specific advocacy provision for African and Caribbean men. The development of specific BME mental health advocacy services and of mainstream mental health advocacy services that have developed a specific service for either African or Caribbean or BME communities was more limited. Mainstream mental health services in the sample mainly provided a model of formal, independent, professionalized advocacy organized around individual casework. By contrast, advocacy provided by African Caribbean services was most commonly described as collective or community advocacy. Nearly a third of the mainstream organizations had no system in place for monitoring ethnicity. In the remainder, the uptake of advocacy services by African Caribbean men was typically low in the absence of specific developments or proactive efforts to seek them out. All of the organizations in the sample described providing, or having the potential to provide, the advocacy-related activities for individual African and Caribbean men, summarized in Fig. 3.

image

Figure 3.  Common features of advocacy provision.

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In addition, African and Caribbean and BME organizations also described activities that addressed broader social issues, including:

  • 1
     Interpretation and translation, particularly for African clients;
  • 2
     Help with housing and benefit issues;
  • 3
     Support for families;
  • 4
     Re-establishing social networks;
  • 5
     Befriending.

The purpose of advocacy was a consistent theme, and the way in which these tasks were delivered had a different emphasis across the different organizational models. Survey respondents from the BCVS (i.e. BME– or African and Caribbean–focused) mental health organizations described the development of such services born out of grass-roots community dissatisfaction with mainstream mental health services. The philosophies underpinning such services were explicitly collective and transformative, seeking alternatives to oppressive treatment and a singular medical model as well as seeking to enable service users to address a broad range of social issues that may perpetuate exclusion.

The reluctance of some African and Caribbean men to discus mental health issues was identified by some of the BCVS organizations, who therefore emphasized the image, location and connections of the organization as important considerations in service design. It was also clear that there is a need for proactive strategies to reach out to prospective advocacy partners and to span service sectors, e.g. inpatient, community, police station and prison settings. The importance of choice was raised by some BCVS advocates so that men had the option of not having an advocate from their own community because of concerns about privacy and confidentiality.

The BCVS organizations voiced concerns about capacity and in particular concerns about access to training and supervision and the demands made on such organizations to represent BME communities on planning fora in the absence of a lack of formal recognition of the impact of this upon capacity. Indeed, there was a consensus that the major barrier to the development of high-quality advocacy for African and Caribbean men is sustainable funding for the BCVS, reflecting a lack of understanding about the contribution that these organizations make in the provision of advocacy. The importance of cultural sensitivity was referred to by many of the generic and mainstream mental health advocacy services in the national survey. By contrast, the BCVS organizations identified cultural specificity as highly desirable, pointing to both the difficulties in engaging this client group and their specific needs including the need to outreach to prisons and forensic services and to provide support to families.

Stakeholder interviews

Two additional themes emerged from the stakeholder interviews. First, the need for commissioning to be more systematic and take account of demographic profiles and diversity of need and preferences for provision, with the implications of national initiatives, such as Count Me In,5–7 for advocacy remaining largely unexplored. The commissioners that were interviewed suggested they would prefer to promote mainstreaming advocacy provision for African and Caribbean men rather than develop separate BME services. They indicated that choice is paramount, but cannot always see how this can be delivered. Concerns were also raised about the potential for marginalization of advocacy provided by BCVS, a risk seen as potentially increased by commissioners adopting a more strategic approach to commissioning mental health advocacy services. The second theme emerged from interviews with staff in mental health services. They confirmed the challenges faced by African and Caribbean men particular in inpatient settings:

Racism is endemic in the system and it is reflected in staff attitudes, the way people talk to people. “I’m white, you’re black –do what I say take this”. It also happens in reverse with white patients and black staff.

[Mental health nurse]

This was used to illustrate the need for independent BCVS organizations to raise awareness of cultural needs and to improve knowledge of both advocacy and the position of African Caribbean men in the mental health system. However, this was tempered by concern at criticism of mainstream mental health services from local advocacy and BCVS groups:

..advocacy is seen as an enemy...as interfering. African and Caribbean men are expected to comply-advocacy rocks the nursing boat.

[Mental health nurse]

It was suggested that advocates needed to earn the respect from mental health services through delivering outcomes for the patients, and a dimension of this was a more positive relationship with mental health services.

Synthesis

A synthesis of the data, including an analysis of the strength of the evidence, from the different sources is provided in Table 7. From this, it was possible to identify features of good practice in the provision of mental health advocacy for African and Caribbean men, as summarized in Fig. 4.

Table 7. Comparison of findings from the different data sources
FindingSimilarities between data sourcesDifferences between data sourcesStrength of evidence
  1. BME, black and minority ethnic.

Need in relation to mental health advocacy
 Consistent evidence of negative experiences of mental health servicesMany of the African and Caribbean organizations identified lack of services and concerns about over-representation and compulsory detention in mental health services as the reasons for their development. These concerns were raised to a more limited extent by generic advocacy services. A negative relationship between mental health services and African and Caribbean men was also a major theme within the literature. The consequences included a lack of inclination to seek help or comply with treatment leading to relapse and readmission; poor engagement with mainstream services restricted choices; and increased dissatisfaction with service provision.The focus group data included frequent descriptions of negative interactions with mainstream services, including experiences of stereotyping and verbal/physical abuse, leading to feelings of isolation, mistrust and frustration. There were widespread concerns about overmedication, side-effects and limited alternatives, particularly access to talking therapies. Some positive experiences of mainstream services were also identified and these were usually described in terms of the quality of relationship with individual workers.Strong evidence for negative perceptions and experience of African and Caribbean men in in-patient and secure settings, more negative pathways into care and restricted choices including coercion when in services.
 Concerns about unmet mental health needs through needs being ignored or misinterpretedThis was a major and consistent theme within all the data, most strongly expressed by African and Caribbean men and the organizations supporting them. Examples of positive experiences of needs having been met related either to African and Caribbean–, or BME-focused services, to the ethos of specific mainstream mental health services or to the quality of relationship with an individual worker.The concerns regarding unmet needs and their misinterpretation was particularly evident in the response to the survey from African and Caribbean and BME advocacy services, descriptions of these services and from the focus groups. African and Caribbean services and service users highlighted issues regarding patois being perceived as not requiring interpretation, which can contribute to misunderstandings and misinterpretation. They also pointed to the limited opportunities to have experiences valued, especially cultural and spiritual beliefs.Strong. There are different forms of evidence all pointing to a similar picture in terms of unmet need and negative experiences of mental health care.
Outcomes
 Potential of advocacy to build confidence, change the relationship between service users and services and improve access to appropriate service provision by increasing choicesA range of functions for mental health advocacy to enable African and Caribbean to access high quality services; build their confidence and skills and promote inclusion were identified.The main outcome identified by focus group participants was reduction in medication dosage and side-effects. This was also identified by advocacy organizations. These organizations also framed advocacy in terms of rights and entitlements and viewed advocacy as a mechanisms for increasing choices and involvement in decision-making.Weak. The evidence for outcomes from advocacy was weak. There was little evidence of routine monitoring of advocacy organizations and/or commissioners. Thus outcomes were largely aspirational. Where outcome data was systematically collected it had not been disaggregated on the basis of ethnicity.
Experience of advocacy
 Experience of advocacy to inform preferences for service provisionFocus group participants had limited experience of mainstream mental health advocacy and access to advocacy. Uptake was higher in African and Caribbean and BME mental health or mental health advocacy services (25–90%). Nearly a third of mainstream mental health advocacy organizations had no system in place for monitoring ethnic data. Of those that did, 25% reported low proportional use (0–2%), 25% reported 6–8% and the remaining 20%, all inner city areas reported between 18 and 25%The conceptualization of advocacy and lack of understanding of distinctive needs of African and Caribbean men acts as a barrier to access mainstream provision, unless specific measures had been put in place. Mainstream advocacy organizations do not always recognize the need for these in comparison with BCVS organizations who identify that trust is a key aspect of service design and reflects the negative experience of mental health services.Medium. The evidence for access to and experience of mental health advocacy by African Caribbean men was hampered by the ethnic monitoring not being universal and absence of routine monitoring of outcomes, as noted above. However the literature review and focus groups provided systematic inquiry in this area.
Characteristics of advocacy services
 Importance of shared cultural heritage, framed in terms of trust, community, awareness of cultural issues and black history.Quality of the relationship with the advocate is critical.Stressed by the majority of focus group participants the literature and services that have focused on African and Caribbean men. Mainstream advocacy services in general stress cultural sensitivity and alongside commissioners, a preference for mainstream provision.Mixed. The literature and service descriptions that are written from an AC perspective stress the importance of shared identity and the importance of a shared understanding of discrimination and racism. However the extent to which membership of a BME group is sufficient was not clear.
 Independence from statutory provisionIndependence from service provider organizations emphasized as key organizing principle by the literature, including good practice guidelines and all advocacy organizations.Position of advocacy within BCVS mental health services provides access to a greater range of opportunities and may potentially facilitate recovery and inclusion through working in this holistic way, than stand alone advocacy services.Strong in terms of independence from statutory provision but more mixed in terms of independence from any form of mental health provision, because of the position and development of mental health services by BCVS.
 Provides a choice of advocateAll sources, including generic mental health advocacy services stress that ideally there would be choice with an AC advocacy service or BME advocate available.Some advocates suggested choice would also extend on occasion to the need not to have an advocate from one’s own community – privacy issue.Strong amongst all sources. Questions raised about practical implications of choice, particularly by commissioners.
 Services that are culturally sensitive All primary studies pointed to the importance of this, echoed by advocacy services and focus group participants.Many BCVS organizations and focus group participants went beyond cultural sensitivity to argue that cultural specificity was needed.Strong, although cultural specificity for BCVS organizations and African and Caribbean men interpreted as cultural specificity.
 Accessibility, including use of outreach and other proactive strategiesTimeliness and ease of access stressed by many data sources and particularly focus group participants.Understanding about how to achieve this varied particularly between generic mental health services and BCVs organizations, which were typically more proactive. The importance of partnership highlighted by the research and some services as a mechanism both to increase access and strengthen capacity.Fairly strong across all sources. Although mentioned as important by mainstream mental health advocacy services, attempt to be proactive and seek to engage with African and Caribbean men typically weak.
 CompetenceAdvocates must primarily be good at their job and have excellent inter-personal skills. Dissatisfaction around the funding available for training and supervision expressed to some degree across all data sources. Foundational principles and standards of good practice widely emphasized.Minimum standard of competence more likely to be stressed by organizations that have adopted a model of professional advocacy. Systems of in-house training and supervision variable, reflecting capacity.Medium. Although a consensus about the importance of advocates being competent, what constitutes competency needs further investigation. Relational aspects both with the advocacy partner and status within mental health services important dimensions of this.
 User involvementDesirability of people with experience of using services to take up roles as advocates. Efforts to recruit service users as advocates and volunteers.BME and African Caribbean mental health services initially established and developed by service users. Variable efforts to include service users in management committees and boards of trustees.Weak, not widely mentioned.
Organizational arrangements for advocacy for African and Caribbean men
 African and Caribbean–focused mental health advocacyAfrican and Caribbean or Black and Minority Ethnic (BME) mental health services provide a range of support, including advocacy, but this is not always differentiated from other roles. African and Caribbean advocacy nested within a wider generic mental health advocacy service. Holistic, collective and transformative philosophies References to organic development born out of grass-roots community dissatisfaction with mainstream mental health services. Preference for this type of provision expressed by focus group participantsMembers of the same ethnic group often showed marked differences of experience and preferencesMixed. Strong preference for philosophy and style of provision expressed across data sources, particularly from a BME perspective. Limited evidence that there may be preferences for other forms and difficult to interpret as ethnicity and gender not disaggregated. Focus group participants found it difficult to conceive of different forms of advocacy beyond the particular form experienced; typically advocacy as part of wider BCVS mental health service
 Black and Minority Ethnic-focused mental health advocacyDifferent models: as integral part of wider BME mental health services or as discrete casework advocacy service managed by BME mental health service. Improved identification and understanding of needs and can concentrate on BME mental health issuesSome advocates, including BME advocates, highlighted potential for marginalization of black advocacyMixed. Information about service use can be anecdotal rather than based on formal record keeping or review. Where monitoring does take place it may not be in sufficient detail to disaggregate for gender or particular minority communities. Strong indication that commissioning to be more systematic and take account of demographics and need
 Generic mental advocacyGeneric mental health advocacy services focus largely on a model of formal, independent, professionalized advocacy organized around individual casework. Sense that services do not adequately facilitate uptake of their service by African Caribbean men. Despite existence of equal opportunities policies, uptake of generic mental health advocacy services is generally low. This is not the case where the generic mh advocacy service has developed specific provision. Lack of specificity in service level agreementsEvidence of satisfaction with generic mental health advocacy when used by African and Caribbean men with no alternative provision Evidence that some commissioners would prefer to promote a mainstreaming strategy rather than have separate BME servicesMixed. Information about service use is often anecdotal rather than based on formal record keeping or review. Despite this strong indication that generic mental health advocacy services, despite good intentions, are not successful at engaging African and Caribbean men unless specific measures have been put in place to facilitate uptake. Capacity within this sector likely to be better developed
Organizational barriers and facilitators for the development of appropriate advocacy for African and Caribbean men
 Resources, particularly sustainable fundingLack of resources and insecurity of funding was identified as the main impediment to sustaining projects and the further development of advocacy. Reliance on the statutory sector for funding and support can limit development because there can be a reluctance to change and recognize that one service does not fit all and the agenda is dominated by central policy rather than local service users’ voices.Capacity and sustainability under threat particularly lack of funding. Also sense that BBCVS not valued and that unreasonable expectations are placed on them by the mainstream.Strong across all sources. Position of BCVS appeared more fragile than mainstream advocacy provision, arising from a lack of understanding about role and task.
 Availability of organizations able to provide advocacy to BME groupsAppropriate provision dependent on availability of organization with capacity e.g. only one BME organization for the whole of Wales. No BVCS providing advocacy in Northern Ireland. Medium, given the limitations of mainstream mental health advocacy services identified above.
 Leadership and managementLeadership and management are not always differentiated from advocacy role. The manager often a practicing advocate. Weak, little mention
 StaffingVariability in staffing of projects. More often than not advocacy projects are small and have few staff. Difficulties in meeting all the potential need even within established BCVS advocacy organizations. A range of options for developing skills and building capacity identified.Reflecting the funding and organizational position of advocacy, BCVS likely to have less dedicated capacity and resources for training.Strong. Data on staffing collected as part of national survey.
 Partnership between organizationsImportance of BME organizations working in partnership with key mainstream organizations.A few positive examples cited but limited. Conversely some mention was made of negative impact on continuity of support arising from difficulties between specific projects and mainstream services arising from different ideologies.Weak, little mention
 Collective advocacy and service user involvementAll projects to some degree have an element of collective advocacy. This is more prominent in BCVS, but generic casework advocacy also typically have arrangements for raising collective concerns, especially those that frequently reoccur in services.BVCS adopt collective challenges to services and models of practice that are implicitly about the location and treatment of people from BME communities in psychiatric services and wider society.Medium. Type of advocacy mapped against a conceptual framework enabling comparison, but for limited sample.
image

Figure 4.  Features of good practice in the provision of advocacy to African and Caribbean men.

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Six main organizational factors that operated as either facilitators or barriers to implementation of these principles were also identified from the synthesis of the data and these are summarized in Table 7. The importance of resources to develop culturally appropriate advocacy, particularly sustainable funding, was strong across all data sources. The position of the BCVS appeared more vulnerable than the advocacy sector in general, with the suggestion that this reflected a lack of understanding about the broader role that advocacy played in tackling wider socioeconomic inequalities for African and Caribbean men. Allied to this was the importance of staffing with BCVS organizations less likely to have dedicated capacity for advocacy, although still providing the function. The availability of organizations able to provide advocacy to BME groups, and the provision of collective advocacy and service user involvement also emerged as facilitating good practice. Finally, although reference was made to leadership and to partnership working between mainstream organizations and the BCVS, this was limited, largely to material identified during the literature review.28

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

The last 10 years have seen significant developments in mental health advocacy, with two main strands. First, the development of standards, whose aim is to strengthen the quality and accountability of current provision14. Second, the emergence of IMHA and a professional role for advocates, enshrined within the Mental Health Act 2007.10 A key finding of the review is the dearth of relevant studies of mental health advocacy of African and Caribbean men, despite a growing understanding of the negative experiences of service users from these communities within the mental health system and the valuable role of community organizations and networks in promoting recovery and inclusion. This partly reflects a lack of evidence in relation to the outcomes of mental health advocacy in general.

The findings support the potential of advocacy as a mechanism for improving the access and experience of African and Caribbean men of mental health services. All the data sources pointed to the consequences of a negative dynamic in terms of poor engagement with mainstream services reflecting a fundamental mistrust of statutory services, restricted choices, increased dissatisfaction with service provision and high levels of unmet need.

The findings indicated that in general the development of mental health advocacy provision has been ad hoc. As Fig. 2 illustrates, advocacy and its purpose can be conceptualized differently in terms of two dimensions: independence/interdependence and empowerment/protection. Independence of advocacy from mainstream provision was identified as a key organizing principle in the standards and service descriptions, particularly those from mainstream generic and mental health advocacy services. From the results of the literature review and the national survey, it was evident that the independence of advocacy provision by the BCVS can be ambiguous as it is often provided as part of a broader range of services designed to meet the specific needs of African and Caribbean men or wider BME communities. The development of advocacy in this way was often attributed to a grassroots response to an evident gap in mainstream provision and was typically guided by a holistic philosophy stressing connections with family, community including faith organizations and culture and thus articulated as a collective as well as an individual enterprise. Thus, our findings resonate with those from Rai-Atkins et al.,14 suggesting that the purpose and nature of mental health advocacy has a different emphasis within BME communities, reflecting not only the experiences of those communities in relation to mental health services but also wider social inequalities, which in turn are linked to poor mental health.29 This raises questions about the narrow definition of advocacy in the statutory duty and thus the impact of the introduction of IMHA services on advocacy provision and the outcomes achievable as a result. Further, mainstream mental health advocacy services appeared to be better resourced but their understanding of the particular challenges faced by African and Caribbean men and thus their conception of advocacy outcomes and capacity to meet the distinct cultural needs of African and Caribbean men more limited.

Whilst there is an on-going debate about whether or not specific mental health services should be developed to meet the distinct needs of BME, in this instance African and Caribbean communities,30 relatively little attention has been paid to advocacy provision. Our findings support the view that it is the advocacy relationship that is paramount (and once established, this can surmount any initial mistrust) – but for many people, perhaps especially those who have negative (racialized) experiences of psychiatry, trust is first and foremost built on recognition of shared ethnicity – and for some this will either open up or close down the possibilities for commencing a relationship in the first place. Thus, our data support the development of culturally specific services to meet the distinct needs and address the disproportionately negative experiences of mental health services and broader social inequalities experienced by African and Caribbean men. Other studies however have emphasized advocate characteristics, other than shared cultural heritage. Bowes et al. (2002)31 found language and specialist knowledge identified as key advocate attributes. They also found that there was no systematic inter-ethnic variability, with members of the same ethnic group often showing marked differences of experience and preferences. The Mind Inquiry32 reported that the majority of Black Caribbean service users in their study valued respect and results more highly than cultural identification. However, both of these studies focus on advocate characteristics and do not explore underpinning conceptions of advocacy that might influence service design and delivery.

Overall, our study did not identify a single preferred organizational model for the development of mental health advocacy for African and Caribbean men. It has, however, identified a range of potential options and modelled them against two major parameters for service provision. We have identified the potential for significant weaknesses with current arrangements. Mainstream mental health advocacy can lack a proactive approach to seeking clients and the ethnic profile of staff, a mistrust of statutory provision and lack of awareness of advocacy provision can serve to inhibit uptake by African and Caribbean men. The lack of ethnic monitoring compounded by ad hoc development raises serious questions about equitable access to appropriate provision. Concerns about negative experiences of mental health services have been a major driver for developments by BCVS organizations. However, the capacity of these organizations to deliver advocacy is seriously compromised by a lack of sustainable funding. This is common across the advocacy sector and for other groups, and our study raises the question of the future funding of advocacy services to ensure equitable access, in the context of diminishing public sector expenditure. The introduction of a statutory duty for qualifying patients under the Mental Health Act will promote the development of independent professional models of advocacy, based on a conception of protecting rights. This has the potential to skew investment and disadvantage other models of advocacy, including collective and community advocacy.

Finally, this study has indicated the need for further research on the impact of advocacy on the use of mental health services, satisfaction with care, and mental health and broader social outcomes for African and Caribbean men and the relationship between different organizational models for provision and this range of outcomes.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

This review provides evidence for the need to develop advocacy as a mechanism to improve access and experiences and thus mental health outcomes for African and Caribbean men. However, good practice in advocacy provision means addressing the double discrimination of racism and mental illness underpinned by a conception of advocacy as a collective as well as an individually focused enterprise. This study has highlighted the central contribution that African and Caribbean and BME organizations, including those that provide mental health services, play in providing advocacy to African and Caribbean, and other communities. However, these organizations often face serious capacity issues and require sustainable investment to develop and provide high-quality advocacy services. Alongside, this a critical examination of the extent to which mainstream mental health advocacy services are meeting the advocacy needs of people from diverse local communities is needed to address the inequities in advocacy provision.33

This indicates that commissioners and providers of mental health advocacy services should ensure that service design is informed by an understanding of the heterogeneity of BME communities: diversity of need in relation to advocacy, the barriers and facilitators to service use and preferences for service provision. The introduction of the statutory duty for advocacy, under the Mental Health Act 2007, makes this review of local arrangements and investment in further development, particularly timely. It is clear that the design and delivery of IMHA services will impact upon uptake by qualifying patients from different backgrounds and that considerations of diversity are thus critical to the provision of effective high-quality IMHA services.34,35

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

We are grateful to the following colleagues for their contributions to our research – Evette A. Hunkins-Hutchinson, Julie Jaye Charles and Zemikael Habte-Mariam, Equalities National Council; Dennis Mullings and Anthony Stephens, Manchester African and Caribbean Mental Health Service; Linda Coleman-Hill and Keith Holt, Lancashire Advocacy. Figure 2 and Table 4 are from Newbigging K, McKeown M, Hunkins-Hutchinson E, French B. Mtetezi: Mental health advocacy with African and Caribbean Men. London: Social Care Institute for Excellence (SCIE), 2007; reproduced here with the kind permission of the Social Care Institute for Excellence.

Conflict of interests

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References

Mick McKeown is the author of one of the papers in the in-depth analysis and was a member of the Steering Group for the development of Mind’s service user standards for advocacy [MIND. (2006). With us in mind: Service user recommendations for advocacy standards in England. London: Mind]. He was therefore not involved in reviewing these papers.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. Aim
  6. Methodology
  7. Systematic review
  8. Primary research
  9. Analysis and synthesis
  10. Limitations
  11. Ethical approval
  12. Results
  13. Discussion
  14. Conclusion
  15. Acknowledgements
  16. Conflict of interests
  17. Sources of funding
  18. References
  • 1
    Silvera M, Kapasi R. Health Advocacy for Minority Ethnic Londoners. Putting Services on the Map. London: Kings Fund, 2000.
  • 2
    Keating F. African and Caribbean men and mental health. Race Equality Foundation Briefing paper 5. Race Equality Foundation, 2007.
  • 3
    Browne D. Black People and Sectioning: the Black Experience of Detention Under the Civil Sections of the Mental Health Act. London: Little Rock Publishing, 1997.
  • 4
    Bhui K, Stansfeld S, Hull S, Priebe S, Mole F, Feder G. Ethnic variations in the pathways to and use of specialist mental health services. British Journal of Psychiatry, 2003; 182: 105116.
  • 5
    Healthcare Commission, Mental Health Act Commission, National Institute for Mental Health England. Count me in: Results of a National Census of Inpatients in Mental Health Hospitals in England and Wales. London: Healthcare Commission, 2005.
  • 6
    Healthcare Commission, Mental Health Act Commission, National Institute for Mental Health England. Count me in: Results of the 2006 National Census of Inpatients in Mental Health and Learning Disability Services in England and Wales. London: Healthcare Commission, 2007.
  • 7
    Healthcare Commission, Mental Health Act Commission, National Institute for Mental Health England. Count me in 2008 Results of the 2008 national census of inpatients in mental health and learning disability services in England and Wales. 2008.
  • 8
    Keating F, Robertson D, McCulloch A, Francis E. Breaking the Circles of Fear: a Review of the Relationship Between Mental Health Services and African and Caribbean Communities. London: Sainsbury Centre for Mental Health, 2002.
  • 9
    Department of Health. Delivering Race Equality in Mental Health Care: an Action Plan for Reform Inside and Outside Services: and the Government’s Response to the Independent Inquiry into the Death of David Bennett. London: Department of Health, 2005.
  • 10
    HM Government. Mental Health Act. London: HMSO, 2007.
  • 11
    Department of Health. Mental Health Act 2007: Independent Mental Health Advocacy. Mental Health Act 1983 (independent Mental health advocates (England) regulations 2008 130 (6)(d) arrangements. Independent mental health advocacy: guidance for commissioners: statement of Equalities Impact Assessment. 2009.
  • 12
    National Institute for Mental Health in England. The Mental Health Act 2007: Independent Mental Health Advocacy for Detained Patients. London: National Institute for Mental Health in England, 2009.
  • 13
    Newbigging K, McKeown M, Hunkins-Hutchinson E, French B. Mtetezi: Mental Health Advocacy With African and Caribbean Men. London: Social Care Institute for Excellence (SCIE), 2007.
  • 14
    Rai-Atkins A, Jama AA, Wright N et al. Best Practice in Mental Health: Advocacy for African, Caribbean and South Asian Communities. Bristol: Policy Press, 2002.
  • 15
    See for example Action 4 Advocacy. Quality standards for advocacy schemes, 2006. Available at: http://www.aqvx59.dsl.pipex.com/Quality%20Standards%20Doc.pdf, accessed 18 December 2010.
  • 16
    Newbigging K, Habte-Mariam Z, McKeown M. Service User Involvement in Systematic Reviews: Mtetezi: Mental Health Advocacy With African and Caribbean Men. London: Social Care Institute for Excellence, 2009.
  • 17
    Pawson R, Boaz A, Grayson L, Long A, Barnes C. Types and Quality of Knowledge in Social Care. SCIE (Knowledge Review 3). London: Social Care Institute for Excellence, 2003.
  • 18
    Long AF, Grayson L, Boaz A. Assessing the quality of knowledge in social care: exploring the potential of a set of generic standards. British Journal of Social Work, 2006; 36: 207226.
  • 19
    Agree Collaboration. Appraisal of Guidelines for Research and Evaluation. 2001. Available at: http://www.agreecollaboration.org, accessed 18 December 2010.
  • 20
    Carlisle S. Health promotion, advocacy and health inequalities: a conceptual framework. Health Promotion International, 2000; 35: 369376.
  • 21
    Spencer L, Ritchie J, Lewis J, Dillon L. Quality in Qualitative Evaluation: Government Chief Social Researcher’s Office. London: Cabinet Office, 2003.
  • 22
    Barnes D, Tate A. Advocacy from the outside inside: a review of the patients’ advocacy service at Ashworth Hospital. University of Durham/Ashworth Hospital Authority/North West Region NHS Secure Commissioning Team.
  • 23
    Foley R, Platzer H. Place and provision: mapping mental health advocacy services in London. Social Science and Medicine, 2007; 64: 617632.
  • 24
    Chouhan K, McAttram M. Towards a Blueprint for Action: Building Capacity in the Black and Minority Ethnic Voluntary and Community Sector Providing Mental Health Services. London: Greater London Authority, 2005.
  • 25
    Christie Y, Hill N. Black Spaces Project. London: Mental Health Foundation, 2003.
  • 26
    Watters C. Inequalities in mental health: the inner city mental health project. Journal of Community & Applied Social Psychology, 1996; 6: 383394.
  • 27
    Phillips M. Ipamo: an alternative to hospital for the African and Caribbean communities in Lambeth. Mental Health Review Journal, 1997; 2: 1821.
  • 28
    Silvera M, Kapasi R. Health Advocacy for Minority Ethnic Londoners: Putting Services on the Map. London: Kings Fund, 2000.
  • 29
    McClean C, Campbell C, Cornish F. African-Caribbean interactions with mental health services in the UK: experiences and expectations of exclusion as (re)productive of health inequalities. Social Science & Medicine, 2002; 56: 657669.
  • 30
    Bhui K. Should there be separate psychiatric services for ethnic minority groups?The British Journal of Psychiatry, 2003; 182: 1012.
  • 31
    Bowes A, Valenti M, Sim D, Macintosh S. Delivering Advocacy Services to Glasgow’s Black and Minority Ethnic Communities: Report to Glasgow City Council and Greater Glasgow Health Board. University of Stirling, Glasgow: Dept. of Applied Social Science; Glasgow, Scotland; Greater Glasgow Health Board, 2002.
  • 32
    MIND. With us in Mind: Service User Recommendations for Advocacy Standards in England. London: Mind, 2006.
  • 33
    Equalities and Human Rights Commission. Mapping advocacy in social care . Available at: http://www.equalityhumanrights.com/our-job/procurement-opportunities/tender-for-mapping-advocacy-in-social-care/, accessed 23 February 2011.
  • 34
    Department of Health. Mental Health Act 2007: Independent Mental Health Advocacy . Statement of Equalities Impact Assessment. 2009. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_092057.pdf, accessed 23 February 2011.
  • 35
    National Institute for Mental Health in England2008: Independent Mental Health Advocacy: guidance for Commissioners . Available at:http://www.virtualward.org.uk/silo/files/imha-guidane-for-comms-15-jan-2009.pdf, accessed 28 April 2010.
  • 36
    Foley R, Platzer H. A Good Place to talk: Mapping Mental Health Advocacy Services in London using GIS Presentation to the Geo Health conference. Wellington, New Zealand: Victoria University, 2002.
  • 37
    McKeown M, Bingley W, Denoual I. Review of Advocacy Services at the Edenfield Regional Secure Unit and Bowness High Dependency Unit. Prestwich Hospital. Preston: University of Central Lancashire, 2002.
  • 38
    Coleman C, Dunmur J. Surveying mental health advocacy needs in Sheffield. Sheffield: Sheffield Community Health Council, 2001.